PAEDIATRIC FLUIDS RCH DEHYDRATION

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1 PAEDIATRIC FLUIDS RCH DEHYDRATION

2 AIMS Understand normal fluids electrolyte requirements/ maintenance Understand how to assess DEHYDRATION in children Understand the difference between DEHYDRATION and SHOCK but that they may occur together

3 RCH FLUID CALCULATOR MAINTENANCE FLUIDS

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5 Fluid & Electrolytes Normal Fluid Requirements Body Weight Fluid requirement per day Fluid requirement per hour First 10 kg 100 ml/kg 4 ml/kg Second 10 kg 50 ml/kg 2 ml/kg Subsequent kg 20 ml/kg 1 ml/kg

6 INSENSIBLE LOSSES Caloric content of feeds Ambient temperature humidity of inspired air Fever Stool output usually between 0-10 ml/kg/ day are lost in stools (may exceed 300 ml/kg/ day in diarrhoea) Urinary output usually between 1-2 ml/kg/ hour

7 Fluid & Electrolytes Normal Electrolyte Requirements Body Weight Sodium mmol/kg/day Potassium mmol/kg/day First 10 kg Second 10 kg Subsequent kg

8 DEHYDRATION A condiyon caused by the excessive loss (deficit) of water from the body

9 DEGREE OF DEHYDRATION What are the symptoms and signs of dehydra;on? How do you dis;nguish MILD v MODERATE v SEVERE dehydra;on?

10 WEIGHT Weigh bare child and compare with any recent (within 2 weeks) weight recordings The best method relies on the difference between the current body weight and the immediate pre-morbid weight.

11 MILD DEHYDRATION <4% No clinical signs They may have increased thirst They will have a history of losses eg vomiyng, diarrhoea, increased insensible losses DOCUMENT FREQUENCY/ VOLUME/ DURATION OF LOSSES

12 MODERATE DEHYDRATION 4-6% HISTORY OF LOSSES +/ DECREASED URINE OUTPUT Central Capillary Refill Time> 2 secs Increased respiratory rate Mild decreased Yssue turgor Sunken eyes, fontanelle Dry mucous membranes

13 SEVERE DEHYDRATION > 7% HISTORY OF LOSSES, decreased urine output +/- lethargy CRT > 3 secs Mogled skin Decreased Yssue turgor Other signs of shock Tachycardia Neurological: irritable or reduced conscious level, Hypotension Deep, acidoyc breathing

14 Considering fluids: Degree of dehydrayon (deficit) + Maintenance fluid requirements + Ongoing losses

15 Calculate deficit Degree of dehydrayon expressed as % of body weight e.g. a 10kg child who is 5% dehydrated has a water deficit of 500mls WEIGHT X DEFICIT % X 10 (in ml) = 10 X 5 X 10 = 500 ML The deficit is replaced over a Yme period that varies according to the child's condiyon. Precise calculayons (eg 4.5%) are not necessary The rate of rehydrayon should be adjusted with ongoing assessment of the child.

16 Speed of replacement Replacement may be rapid in most cases of gastroenteriys (best achieved by oral or ng fluids) SLOWER in DKA, meningiys and HYPERNATRAEMIA In Hypernatraemia aim to rehydrate over 48 hours with Na not falling more than 1mmol/litre/hour

17 SHOCK Shock occurs as result of rapid loss of 20 ml/kg from the intravascular space

18 SHOCK The treatment of shock requires rapid administrayon of a bolus of intravascular fluid (start with 10-20ml/kg then reassess) with electrolyte content that approximates to plasma (eg. 0.9% saline) If the intravascular volume is maintained, clinical dehydrayon is only evident aoer losses of >25 ml/kg of total body water.

19 DEHYDRATED BUT NOT SHOCKED The treatment of dehydrayon requires gradual replacement of fluids, with electrolyte content that relates to the to the electrolyte losses, or to the total body electrolyte content.

20 Dehydration diagram

21 RATE OF REPLACEMENT RCH GastroenteriYs Aim for ENTERAL replacement if possible PO NG Ondansetron if >6m/ >8kg 10-20ml/kg over an hour of ORS Ondansetron as above BHS we do SLOW rehydrayon

22 NG fluid replacement Replace deficit over first 6 hours and then give daily maintenance over the next 18 hours. To calculate hourly rate TABLE 3 of the RCH gastroenteriys

23 IV FLUIDS NG is safer and more effecyve but IV rehydrayon is indicated for severe dehydrayon and if NG fails (eg. ongoing profuse losses or abdominal pain) Also suitable for children who already have an IV insitu Certain comorbidiyes, parycularly GIT condiyons (eg. short gut or previous gut surgery) - discuss these payents with senior staff.

24 IV fluid choice (not shocked) Rapid IV Rehydra8on (d/w senior) In older children > 4 years moderate dehydrayon with no comorbidiyes, no electrolyte disturbance and no significant abdominal pain 10 ml/kg/hr (up to 1000ml/hr) for 4 hours 0.9% sodium chloride (normal saline) and 5% Glucose, then reassess.

25 Standard IV Rehydra8on for the first 24 hours. Table 4 RCH guideline Table 4

26 IV FLuids 0.9% sodium chloride (normal saline) and 5% Glucose for rehydrayon aoer any required boluses. If serum K < 3mmol/L, add KCl 20mmol/L, or give oral supplements Measure Na, K and glucose at the outset and at least 24 hourly from then on (more frequent tesyng is indicated for payents with comorbidiyes or if more unwell) Plasmalyte 148 is used in ICU at BHS

27 Monitoring Bare weigh payent 6 hourly in moderate and severe dehydrayon, who are receiving NGTR or iv fluids Carefully reassess aoer 4-6 hours, then 8 hourly to guide ongoing fluid therapy this should be part of morning & ayernoon handover Look parycularly for: weight change clinical signs of dehydrayon urine output ongoing losses signs of fluid overload, such as puffy face and extremiyes.

28 FLUIDS Understand maintenance requirements Understand assessment of dehydrayon DifferenYaYng dehydrayon v shock v dehydrayon & shock Fluid replacement Po Ng Iv fluids